Laserfiche WebLink
.a, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH �FFICr� USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued / - 1 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ? CENSUS TRACT <br /> Owner's NamePhone0::b6ala _4 <br /> �� - <br /> Address City { <br /> Contractor's Name ��?ns,..�� � �6-'f-� License - Phone�c�-. 35� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION / / DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / �_ _ �--- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION•` SP'ECIFICATIONS _'�>,. <br /> Industrial u Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of ;Well Casing <br /> Domestic/public Driven Gauge of Casing j-1-L__j <br /> Irrigation Gravel Pack t Seal <br /> Cathodic Protection Rotary "° rout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> . _ <br /> PUMP REPLACEMENT. / / State Work Done <br /> j PUMP .REPAIR: / / State Work Done � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations o the SanJoaquin Local Health District <br /> and the State of California pertaining to or regulating ell construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnis the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before �utting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRRUTING AND A FINAL INSPECTION. � <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON R VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . DATE - <br /> APPLICATION ACCEPTED BY ,,, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IN/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> 2M <br /> E H 1426 Rev. - 1-74 -- <br />